Table Of ContentSelf-Assessment Colour Review of
Neuroimaging
Edited by
Kirsten Forbes
Institute of Neurological Sciences, Southern General Hospital, UK
Michael H. Lev
Director, Emergency Neuroradiology and Neurovascular Laboratory,
Massachusetts General Hospital, Boston, USA
Sanjay Shetty
Neuroradiology Section, Department of Radiology,
Massachusetts General Hospital, Boston, USA
Joseph Heiserman
Division of Neuroradiology, Barrow Neurological Institute,
St. Joseph’s Hospital, Phoenix, USA
With contributions from
Jason Bearden
Division of Neuroradiology, Barrow Neurological Institute,
St. Joseph's Hospital, Phoenix, USA
Johannes B. Roedl
Department of Radiology, Massachusetts General Hospital, Boston, USA
MANSON
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Preface
This concise volume is a case-based teaching text on imaging of the central nervous
system. The book approaches neuroradiology in a practical day-to-day manner, offering
readers over 100 real-life clinical cases for interpretation. It offers a visual, interactive
mode of learning, designed to stimulate inquisitive thinking on a range of both common
and more unusual neurological conditions.
While primarily written for radiologists, the wide range of cases will also be of
interest to neurologists, neurosurgeons, and those many other physicians whose patients
require imaging of the neuraxis, and who wish to learn more about neuroimaging.
The book is designed to simulate the clinical scenario: cases are presented with a
short clinical history and a selection of pertinent images. A series of questions focuses
the reader’s mind on the important aspects of the case. The diagnosis is revealed on
turning the page, whereby a discussion of not only imaging findings, but also differential
diagnosis, pathology, and clinical correlation follow, and answers to the specific
questions posed are indicated. Where imaging findings could be confused with alternate
diagnoses, then these are shown, or readers are cross-referenced to other relevant parts
of the text. Each case concludes with one or more ‘take-home’ teaching pearls.
This versatile book can be read in many ways: it may be used to test existing
knowledge, which can then be enhanced by the supplementary information provided,
or it can be used as a primary teaching text, whereby readers can select cases from the
index. Regardless, the editors are hopeful that as you read it your interest in this
fascinating subject will be (re)kindled and your knowledge of it will grow greater.
Kirsten Forbes
Michael Lev
Sanjay Shetty
Joseph Heiserman
3
Abbreviations
ACarachnoid cyst EBVEpstein–Barr virus
ACAanterior cerebral artery EDHepidural haematoma
ACCagenesis of the corpus callosum EGeosinophilic granuloma
ACTHadrenocorticotrophic hormone ESRerythrocyte sedimentation rate
ADCapparent diffusion coefficient FLAIRfluid inversion recovery
ADEMacute disseminated GBMglioblastoma multiforme
encephalomyelitis GCgliomatosis cerebri
AEDanti-epileptic drug GREgradient recalled echo
AHEMacute haemorrhagic HIVhuman immunodeficiency virus
encephalomyelitis HSHallervorden–Spatz syndrome
AIDSaquired immunodeficiency HSEherpes simplex encephalitis
syndrome HSVherpes simplex virus
(X-) ALD(X-linked) IACinternal auditory canal
adrenoleukodystrophy ICAinternal carotid artery/inferior
AMLangiomyolipoma cerebral artery
AVMarteriovenous malformation IPHintraparenchymal haematoma
BDEMbiphasic disseminated JPAjuvenile pilocytic astrocytoma
encephalomyelitis LCHLangerhans cell histiocytosis
BGbrainstem glioma LCMlymphocytic choriomeningitis
CAAcerebral amyloid angiopathy LHRHluteinizing hormone releasing
CADASILcerebral autosomal dominant hormone
arteriopathy with subcortical infarct MBmedulloblastoma
and leukoencephalopathy MCAmiddle cerebral artery
CBVcerebral blood volume MELASmitochondrial myopathy,
CECTcontrast enhanced computed encephalopathy, lactic acidosis and
tomography stroke-like episodes
CMcavernous malformation MIPmaximum intensity projection
CMVcytomegalovirus MISMEmultiple inherited
CNcranial nerve schwannomas, meningiomas, and
CNScentral nervous system ependymomas
CPcraniopharyngioma MLDmetachromatic leukodystrophy
CPAcerebellopontine angle MRAmagnetic resonance angiography
CPPchoroid plexus papilloma MRImagnetic resonance imaging
CSFcerebrospinal fluid MRSmagnetic resonance spectroscopy
CTcomputed tomography MRVmagnetic resonance venography
CTAcomputed tomography angiography MSmultiple sclerosis
CVTcortical venous thrombosis MTSmesial temporal sclerosis
DAIdiffuse axonal injury MVAmotor vehicle accident
dAVFdural arteriovenous fistula NAAn-acetyl aspartate
DNETdysembryoblastic neuroepithelial NECTnonenhanced computed
tumour tomography
DSDevic’s syndrome NF 1,2neurofibromatosis type 1,2
DSTdural sinus thrombosis NPHnormal pressure hydrocephalus
DTIdiffusion tensor imaging NSAIDnonsteroidal anti-inflammatory
DWIdiffusion weighted imaging drugs
4
PCAposterior cerebral artery SLEsystemic lupus erythematosus
PCNSLprimary CNS lymphoma SNHLsensorineural hearing loss
PKANpantothenate kinase-associated SODsepto-optic dysplasia
neurodegeneration S-PNETsupratentorial primitive
PMLprogressive multifocal neuroectodermal tumour
leukoencephalopathy STIRshort tau inversion recovery
PNETprimitive neuroectodermal tumour TBtuberculosis
PPPpseudophlebitic pattern TBItraumatic brain injury
PRESposterior reversible TIAtransient ischaemic attack
encephalopathy syndrome TOFtime-of-flight
PXApleomorphic xanthoastrocytoma TORCH(t)oxoplasmosis, (o)ther,
RArheumatoid arthritis (r)ubella, (c)ytomegalovirus, (h)erpes
RLVDretrograde leptomeningeal venous simplex
drainage TSCtuberous sclerosis complex
SDEsubdural empyema VHLvon Hippel–Lindau syndrome
SDHsubdural haematoma WBCwhite blood cell
SIADHsyndrome of inappropriate WHOWorld Health Organization
antidiuretic hormone WMwhite matter
Classification of cases
Abscess, epidural: 106 Craniopharyngioma: 96
Abscess, pyogenic: 83 Cyst, arachnoid: 31
Acoustic schwannoma: 62 dermoid: 42
Acute disseminated encephalomyelitis: epidermoid: 8
90 facet joint: 48
Adrenoleukodystrophy: 19 pineal: 59
Agenesis of corpus callosum: 1 Cytomegalovirus, congenital: 51
Alobar holoprosencephaly: 7 Dandy–Walker malformation: 23
Aneurysm, anterior communicating: 25 Developmental delay:
middle cerebral artery: 81 rhomboencephalosynapsis: 14
Anti-epileptic drug-related white matter septo-optic dysplasia: 82
changes: 29 Devic’s syndrome: 9
Arachnoiditis: 97 Diffuse axonal injury: 73
Arteriovenous malformation: 32 Disc herniation, right C6/7: 15
CADASIL: 58 Dural arteriovenous fistula: 11
Cavernous malformation: 52 Dysembryoblastic neuroepithelial
Cerebral amyloid angiopathy: 71 tumour: 5
Chondrosarcoma: 91 Ependymoma: 109
Choroid plexus carcinoma: 108 Epidural haematoma: 45, 63
Choroid plexus papilloma: 102 Epidural lipomatosis 60
Cord degeneration: 26 Extracranial ICA dissection: 46
5
Germinoma: 38 Multiple sclerosis: 64
Gibb’s artifact: 16 Nerve root avulsions 94
Glioblastoma multiforme: 77 Neurocysticercosis: 85
of the cord: 35 Neurocytoma, central: 98
Glioma, low-grade astrocytoma: 30, 49 Neurosarcoid: 55
focal pontine brainstem: 53 Oligodendroglioma: 20
ganglioglioma: 10 Optic neuritis: 2
optic chiasm (juvenile pilocytic Osmotic demyelination syndrome: 65
astrocytoma): 100 Pineoblastoma: 18
tectal: 57 Pineocytoma: 67
Gliomatosis cerebri: 27 Pituitary macroadenoma: 107
Gunshot injury: 70 microadenoma: 92
Hallervorden–Spatz syndrome: 104 Pleomorphic xanthoastrocytoma: 6
Haemangioblastoma: 111 Posterior reversible encephalopathy
Haemangiopericytoma: 43 syndrome: 87
Haemorrhagic contusion: 72 Primary CNS lymphoma: 56
Haemorrhagic metastases: 59 Progressive multifocal
Herpes simplex encephalitis: 54 leukoencephalopathy: 21
Hydrocephalus: 110 Prostate metastasis: 36
normal pressure: 112 Pyogenic abscess: 83
Hypothalamic hamartoma; 93 Ruptured aneurysm: 81
Hypoxic injury, severe diffuse 101 Ruptured dermoid: 42
Infarction, acute left middle cerebral Septo-optic dysplasia: 82
artery: 22 Spinal epidural abscess: 106
Juvenile pilocytic astrocytoma: 105 Spinal trauma (Jefferson fracture): 113
Langerhans cell histiocytosis: 33, 84 Sturge–Weber syndrome: 80
Leptomeningeal and parenchymal Subclavian steal syndrome: 12
compartment lesions (synchronous): 28 Subdural empyema: 44
Limbus vertebra: 40 Subdural haematoma (acute): 39
Lipomyelomeningocoele 17 Subependymoma: 89
Lyme disease: 68 Supratentorial primitive neuroectodermal
Lymphocytic hypophysitis: 37 tumour: 24
Lymphoma: 86 Synovial cyst, right facet joint: 48
Malignant melanoma: 75 Thrombosis, deep cerebral venous: 66
Marrow replacement, diffuse 99 cortical: 78
Medulloblastoma: 103 dural sinus: 78
MELAS 88 Tuberculosis: 28, 47
Meningioma: 95 Tuberous sclerosis: 13
Meningitis, carcinomatous: 41 Vasculitis: 76
pneumococcal: 50 Vertebral haemangioma: 4
Mesial temporal sclerosis, right: 3 Vertebral osteoid osteoma: 34
Metachromatic leukodystrophy: 61 Wallerian degeneration: 79
Moyamoya: 74 Wernicke encephalopathy: 69
6
1: Question
1A 1B
1C 1D
1A 6-month old child presents with seizures.
i.Describe the features shown on imaging (1A,B).
ii.What is the diagnosis?
iii.What are its associations?
iv.How does the companion case shown (1C,D) differ?
7
1: Answer
1 DIAGNOSIS Agenesis of the corpus 1E
callosum (ii).
2
IMAGING FINDINGS The sagittal T1-
weighted MRI image (1A) reveals 1
agenesis of the corpus callosum (ACC).
This is the largest white matter
commissure in the brain, lying in the
midline, where it connects the two
cerebral hemispheres (1E, arrow 1).
Normal development of the corpus
callosum is associated with inversion of
the cingulate gyrus forming the cingulate
sulcus, which parallels the corpus
callosum superiorly (1E, arrow 2). Thus, in ACC, the cingulate sulcus is absent,
causing the medial hemispheric sulci to radiate into the roof of the 3rd ventricle (1A,
arrow). The axial T1-weighted MRI (1B), reveals the resultant high-riding 3rd
ventricle extending superiorly between parallel lateral ventricles (arrow). The trigones
and occipital horns of the lateral ventricles are often dilated in ACC, termed
colpocephaly (i).
PATHOLOGYANDCLINICALCORRELATION The corpus callosum forms during the first
trimester and its absence (agenesis) or incomplete formation (hypogenesis) may result
from one of many different genetic mutations. Associated developmental anomalies
are common and include Chiari II malformation, Dandy–Walker malformation, and
disorders of neuronal migration and organization. ACC is also a feature of many
different syndromes, for example Aicardi syndrome. In this X-linked syndrome, ACC
is associated with an interhemispheric cyst, cortical dysplasia (commonly poly-
microgyria), grey matter heterotopia, and hypoplasic cerebellum (iii).
COMPANION CASE
DIAGNOSIS Hypogenesis of the corpus callosum with interhemispheric lipoma.
IMAGINGFINDINGS The sagittal T1-weighted MRI image (1C) shows that only part of
the corpus callosum has formed (anterior body). The posterior body, splenium, and
rostrum of the corpus callosum are absent. On both the T1-weighted image and the
coronal T2-weighted image (1D), a focal hyperintense mass is seen in the midline,
posterior and superior to the formed corpus callosum (arrow). This is an interhemi-
spheric lipoma, which is almost always associated with agenesis or hypogenesis of the
corpus callosum.
8
